The far lateral/combined supra- and infratentorial approach

A human cadaveric prosection model for routes of access to the petroclival region and ventral brain stem

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✓ A far lateral approach to the ventral brain stem, lower clivus, and anterior foramen magnum is described. Methods for further exposure of the superior petroclival region by incorporating a subtemporal craniotomy and posterior petrosectomy are also demonstrated. Eight sequentially illustrated steps depict this technique. The far lateral/combined supra- and infratentorial exposure is a comprehensive surgical approach that provides direct access to the entire anterior and lateral brain stem and craniovertebral junction. It minimizes brain-stem retraction and maximizes visualization of the neurovascular structures.

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Address reprint requests to: Robert F. Spetzler, M.D., c/o Editorial Office, Barrow Neurological Institute, 350 West Thomas Road, Phoenix, Arizona 85013.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Drawing demonstrating the modified park-bench position for operative exposure in the far lateral/combined approach. The head is positioned about 15° below the horizontal plane.

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    Drawing indicating placement of operative incision for the far lateral approach (A), which begins at the mastoid process and moves in a curvilinear fashion below the superior nuchal line toward the midline. A modification of the far lateral incision (B) allows petrous bone exposure and/or a subtemporal craniotomy.

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    Drawing showing external landmarks exposed via the far lateral/combined incision, including the zygoma, lateral temporal bone, external auditory meatus, and mastoid region. Note that the cuff of the splenius capitis muscle is preserved for reattachment during closure.

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    Photographs (left) and drawings (right) illustrating vertebral artery dissection and bone exposure. Upper: Craniocervical junction exposure during the initial far lateral approach, showing the atlanto-occipital joint, C-1 ring, posterior condylar emissary vein (PCEV), and vertebral venous plexus. Center: Hemilaminectomy of C-1 is performed with a drill. Lower: Mobilization of the vertebral artery at the level of the transverse foramen.

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    Drawing illustrating a suboccipital craniotomy at the level of the foramen magnum, medial to the jugular tubercle, the sigmoid sinus, and the condylar emissary vein.

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    Drawing illustrating protection of the extracranial vertebral artery, while the atlanto-occipital joint is drilled.

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    Photograph illustrating the jugular tubercle (asterisk) from an inferior basal view.

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    Photograph (left) and drawing (right) illustrating exposure of the foramen magnum and removal of its lateral aspect, the jugular tubercle, and the posteromedial two-thirds of both the occipital condyle and the C-1 lateral mass.

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    Drawing depicting the posterior fossa dural opening at the craniocervical junction which extends below the level of the vertebral artery and laterally.

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    Photograph (left) and drawing (right) of the intradural stage of the procedure, showing retraction of the dural opening for the far lateral component of the exposure. Note the low origin of the posterior inferior cerebellar artery (PICA). CN XI = 11th cranial nerve.

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    Photograph (left) and drawing (right) showing a microdissection view of the dorsal relationships of the ninth, 10th, 11th, and 12th cranial nerves (CN IX, X, XI, and XII) to the vertebral artery. PICA = posterior inferior cerebellar artery.

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    Drawing depicting expansion of the far lateral craniotomy to include the posterior temporal, lateral suboccipital, and retrosigmoid regions.

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    Drawings depicting petrosectomy. CN = cranial nerve. Left: Retrolabyrinthine exposure of the petrous bone, demonstrating preservation of the semicircular canals, but a limited view toward the anterior clival apex. The dural incision is indicated by the broken line. Right: Translabyrinthine/transcochlear petrosectomy, revealing an extended view of the anterior clival apex with mobilization of the facial nerve. TMJ = temporomandibular joint.

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    Drawing depicting dural openings for the combined supra- and infratentorial approach, showing division of the superior petrosal sinus with continuation of the incision toward the tentorial incisura.

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    Photographs (left) and drawings (right) illustrating combined dural approaches. CN = cranial nerve; PCA = posterior cerebral artery; SCA = superior cerebellar artery; P-Com = posterior communicating artery; AICA = anterior inferior cerebellar artery; PICA = posterior inferior cerebellar artery. Upper: Intradural combined far lateral approach with retrolabyrinthine petrosectomy. Lower: Intradural exposure of complete approach with transcochlear petrosectomy.

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